What is involved in the term "death with dignity"?
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Debates around this question generally fall into two categories: physician-assisted suicide and euthanasia. These terms are often used interchangeably; however, the distinctions are significant. The act of physician-assisted suicide involves a medical doctor who provides a patient the means to kill him or herself, usually by an overdose of prescription medication.

Euthanasia involves the intentional killing of a patient by the direct intervention of a physician or another party, ostensibly for the good of the patient or others. The most common form of euthanasia is lethal injection. Euthanasia can be voluntary (at the patient's request), non-voluntary (without the knowledge or consent of the patient) or involuntary (against his or her wishes).

Because I believe that each human life is significant and unique, the taking of innocent life is a role specifically relegated to God, not man.

Physician-assisted suicide and euthanasia violate the sanctity of human life, so I oppose both.

People living with terminal illness deserve more than the offer of a physician to facilitate their death. They merit true compassion. Accessing expert palliative (hospice) care and comfort care — treating the symptoms and making the patient as comfortable as possible during the natural dying process. Palliative (hospice) care differs from acute care in that it becomes appropriate when aggressive therapies are no longer beneficial to the patient and there is no longer an attempt to cure the disease.

 Barriers need to be removed that prevent patients from receiving available treatments for pain and other symptoms — not alleviate the safeguards that protect patients from psychological or financial coercion to choose an untimely death. The goal should not be to legalize physician-assisted suicide but rather to adequately provide available means of care so that patients and their families do not feel the need to consider an early death.

Social acceptance of physician-assisted suicide sends the message that some lives, especially those of elderly, disabled and dependent citizens, have less value, and are not worth living.

The practice of physician-assisted suicide creates a duty to die. Death may become a reasonable substitute to treatment and care as medical costs continue to rise. The patient, and the family members may be encouraged to use this option and be pressed to do so, to alleviate this burden, on the hospital or nursing home, as much as on the one suffering.

Better medical alternatives exist to physician-assisted suicide.  However, they are not brought to the light as much as they should, family members need to be more engaged, and aggressive in becoming informed to the resources available. Today's pain management techniques can provide relief for up to 95 percent of patients, thus offering true death with dignity. 
Physician-assisted suicide often ignores anxiety, depression, and family problems, which is a legitimate cry for help.

Physician-assisted suicide gives too much power to doctors, threatening patient autonomy by allowing physicians to decide whether a patient lives or dies. This is occurring now in  the Netherlands, Europe.

The practice of physician-assisted suicide threatens to destroy the delicate trust relationship between doctor and patient – a relationship based on the patient's belief that his or her physician will pursue the goal of protecting life.
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Physician-assisted suicide opens the door to euthanasia. Then, when this boundary is overstepped, where is this going to lead? Where will this mindset go next? Who else will be termed “better off dead?”

"In a society as obsessed with the costs of health care and the principle of utility, the dangers of the slippery slope... are far from fantasy...

Assisted suicide is a half-way house, a stop on the way to other forms of direct euthanasia, for example, for incompetent patients by advance directive or suicide in the elderly. So, too, is voluntary euthanasia a half-way house to involuntary and non-voluntary euthanasia. If terminating life is a benefit, the reasoning goes, why should euthanasia be limited only to those who can give consent? Why need we ask for consent?" 

It must be recognized that assisted suicide and euthanasia will be practiced through the prism of social inequality and prejudice that characterizes the delivery of services in all segments of society, including health care. Those who will be most vulnerable to abuse, error, or indifference are the poor, minorities, and those who are least educated and least empowered. This risk does not reflect a judgment that physicians are more prejudiced or influenced by race and class than the rest of society - only that they are not exempt from the prejudices manifest in other areas of our collective life. 

While our society aspires to eradicate discrimination and the most punishing effects of poverty in employment practices, housing, education, and law enforcement, we consistently fall short of our goals. The costs of this failure with assisted suicide and euthanasia would be extreme. Nor is there any reason to believe that the practices, whatever safeguards are erected, will be unaffected by the broader social and medical context in which they will be operating. This assumption is naive and unsupportable."

Above and beyond all of this; the question is, what does God think of this?

Exo 20:13  Thou shalt not kill. 
Deu 5:17  Thou shalt not kill. 
Pastor Lorna Couillard

A family caregiver is often put in the position of providing guidance and advocating for the medical care of an older adult. Communicating with a doctor who treats the older adult can be sometimes awkward.

As a family caregiver, you want to respect the wishes and dignity of the older adult you care about. However, sometimes older adults may not ask questions or be self-advocates with medical providers.

If you go to doctor’s visits with your older adult, physicians tend to be willing to speak with you about your older adult’s care. However, it is advisable and many physicians require that a Power of Attorney For Health Care or authorization form be completed, giving you that power. It can be placed in your older adult’s medical file so there is no question that the physician may speak with you about your older adult’s health concerns and treatment without violating any confidentiality rules.

The following are some things to keep in mind and tips for better communicating with your older adult’s medical providers:

Have medical information handy. Always have a current list of your older adult’s prescribed medications, over-the-counter drugs and vitamin supplements being taken when seeing the doctor. Also, when your older adult has blood work or other medical tests done, make sure the doctor gives a copy of each report to you or your older adult. Keep the reports in order by date in a large envelope. Take the reports to doctor appointments, especially when seeing a medical specialist who may not have all records.
Write down concerns and questions. Prior to visiting the doctor, it is best to write down any concerns and questions. Include personal issues with, for example, swallowing tablets or a schedule that may interfere with taking medications. The visit with the doctor is usually short and it is easy to forget everything you want addressed.

Speak up. Make sure you make your key concerns known at the onset of the visit to help prevent the doctor from jumping to conclusions about treatments or dismissing issues you believe are important. Some physicians are less aggressive in treating an older adults for various reasons, including using “age” as a blanket answer for older adult medical problems.

Age, medical cost or personal discomfort of the older adult may be reasons a physician may not prescribe tests or medicines. A good question to ask is: “What treatment, tests or next step would you recommend if he/she was age 40 and had these symptoms?” You and your older adult should be offered the full range of tests and treatments, allowing you and your older adult to decide what may be too uncomfortable or expensive. Ask for referrals to medical specialists or get a second opinion, if that seems like the next logical step.

Ask questions. Don’t hesitate to ask when words the doctor is using are unfamiliar or his instructions are unclear.

Be informed. Learn about your older adult’s illness. Ask the doctor for literature about an illness or have him write down both the medical term and general term for an illness. There is lots of information in libraries, on the Internet and from health groups about health problems. Pharmacists are also great sources for information about medications. Make sure what the doctor and pharmacist say about a medication is not in conflict; if it is in conflict ask them to speak directly to each other.

Keep contact information. You and your older adult should have a current list of the names, addresses, and the office phone and fax numbers of all physicians your older adult is seeing and has seen. Blood work and other tests often should be sent to both a primary doctor and specialist, and you will be asked for address information. Also, if a doctor’s office is unresponsive to your telephone call or you are a long-distance caregiver, faxing your questions in writing to a doctor can sometimes prompt a response.
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Important To Deal With Depression

Depression is one of the most common mental problems affecting older adults. It is also one of the most treatable. Family caregivers often are uncertain about whether they should suggest that their older adults seek professional help. However, in many cases, older adults themselves are aware that they are unhappy but feel uncomfortable about reaching out for help.

The best way to approach your older adult is to express it as concern for his or her health. If anger is part of the older adult’s depression, do not bring up the topic during an angry moment but instead later when emotions are calm.

Generally, there are two types of depression – incidental and clinical. The incidental type of depression is normal, periodic and is in reaction to a life occurrence. Clinical depression is an imbalance in a person’s physiology, often referred to as a “chemical imbalance.” 

Both types of depression can be treated. Sometimes for incidental depression, increased social contact and attentiveness by friends and relatives is all that is needed to get someone out of depression. Physical activity can also reduce feelings of depression. However, if incidental depression lingers over an extended period of time, the personal lifestyle of isolation from others and a negative outlook on life that develops from depression can become a way of life and only medication can help. 

It can be difficult to tell in older adults if depression is incidental or clinical. Older adults, simply because of age deal with issues that may cause depression, such as frequent death of people close to them, physical limitations due to pain and chronic illnesses, and mobility and vision problems that may restrict them from hobbies and social activities. 

Getting a professional opinion, ideally from a geriatric psychiatrist, is the best way to determine if your older adult has a problem with depression. Because older adults react differently to medications due to having slower metabolisms and special sensitivities, a psychiatrist with training in geriatric care is best. However, if a geriatric specialist isn’t available, at least turn to a psychologist or psychiatrist – not a general physician – for mental health treatment. 

With proper medical treatment for depression, an older adult will likely become more socially and physically active. Often medical treatment for depression can result in unexpected improvements in addition to reducing depression, such as increased mental clarity and memory, less pain, less gastronomic and headache problems, and positive changes in other physical disorders. 

Interrupted sleep is common among adults age 70 and over. Treatment for depression can also improve sleep and result in greater personal energy for an older adult.

How do you know when an older adult’s depression is a normal part of life or in need of medical attention? Lack of doing normal activities and isolation from social contact are good indicators that there is a problem. Also, often there are specific emotional, cognitive, physical and behavioral symptoms.

The following are symptoms in each category:

Emotional: crying, apathy, lack of feeling or interest, and overall dissatisfaction with life. 

Cognitive: memory problems, disorientation, decreased attention span, feeling pessimistic, low self-esteem, hopelessness, difficulty concentrating, suicidal thoughts and dwelling on past failures. 

Physical: headaches, weight loss or gain, stomach distress, sleep disturbances, pain and fatigue. 

Behavioral: reduced activity, obsessive worrying, hostile, agitation, irritable and restlessness. 

In addition to being concerned about your older adult and possible depression, make sure to note if you are having symptoms of depression and get medical attention, if necessary. Also, consider taking a break from caregiving, if it is causing you stress. It may be all you need to regain a positive perspective on life.

Personal Care Is Important 
Proper daily hygiene and dental care, adequate intake of water and other personal care concerns are important for family caregivers to take note of with their older adults. Long-term lack of personal care can lead to serious health problems. 

Poor personal cleanliness can be a symptom of low self-esteem due to depression or other mental health problem, mobility limitations or lack of energy from interrupted sleep or a physiological problem such as a thyroid imbalance. 

Poor dental care can also be a symptom of low self-esteem due to depression or other mental health problem. Or, an older adult may not be able to afford dental care, have transportation to get to dental appointments or could have problems gripping a toothbrush due to pain from arthritis or other ailment. 

Dehydration is prevalent among older adults. The normal physiological triggers that prompt thirst lessen with age. Dehydration can lead to symptoms of dizziness and weakness, and may cause heart and other serious health problems if not addressed. 

Poor personal hygiene can lead to skin and hair problems. Lack of dental care may result in an older adult not eating properly because of pain with chewing or lack of teeth to chew. A serious lack hygiene and/or dental care can lead to skin and gum sores, infections and chronic diseases that can develop from sores. 

If an older adult is not keeping up with personal care, make a list of your concerns and address them with your older adult. Approach the issues as health concerns without being critical of your older adult. If this doesn’t help, make an appointment with a primary or geriatric physician and address the concerns with the doctor with your older adult present. A complete mental and physical health evaluation should be done. A doctor’s perspective may help your older adult realize the importance of these issues as they relate to health. 

Older adults need to have a daily routine of personal hygiene and dental care, dress in clean, day clothes (not stay in bed clothes) and maintain a schedule of activities. Regular dental care check-ups should be scheduled and, at a minimum, older adults should have annual check-ups by a physician for preventive health care. 

Many Considerations For Housing & Care

If mental and/or physical frailties become a concern for older adults and their family caregivers, there are now many living options to choose from. The first priority in considering any housing change for an older adult is personal safety. If a living situation is now making the person unsafe, a change needs to be considered. “Unsafe” can be the actual living circumstance (i.e. too many steps to climb) or the person isn’t doing self-care (i.e. eating or hygiene.) 

Changing an older adult’s living situation doesn’t have to mean moving out of the existing home (if the housing situation is safe.) There are now many homemaking, meal delivery and personal care services that will come to an older adult’s home. 

Also, if one person living in the home is able but the other person needs help, having the frail older adult go to an adult day center for one or more days per week may be a good option. Personal care such as bathing can be taken care of at the center. Also, going to the center can provide the frail older adult with socialization and the caregiver with a break from caregiving duties. 

For older adults who want to consider moving from home, there are many options – from senior apartments, some with federal subsidy and others without, to retirement communities that offer unassisted to assisted living situations. 

Moving to housing with a minimum age requirement (usually age 50), can be a positive move. Being with other seniors, there may be more socialization opportunities. Also, if care services are needed, they may be readily accessible 24 hours per day. 

Whether it is an in-home service or special housing, the older adult’s preference must be a priority. Family caregivers can assist with the decision, but an older adult’s wishes need to be respected. Also, it is best to check with several options, interview people, ask detailed questions using check lists and tour housing and facilities. Check any contracts carefully. Housing and services for older adults has become very complex. 
A skilled nursing care facility is required only when specified by a physician. In the case of terminal illnesses determined by a physician, in-home or facility hospice care are options. 

Ask Questions, Consider Options For Home Care

There are several options when trying to find in-home help to care for your older adult. The key is to find reliable help that you and your older adult comfortable with and meets the specific care needs.

Home care is defined by the type of care needed – homemaking, hands-on personal care (i.e. bathing, toileting), and supportive medical care. 

Or, you may hire a care worker independently or through a home health agency. 

When considering a home health agency for a care worker, there are some questions to ask in advance that can assist you getting help which is best suited for your older adult. Before hiring an agency, ask:

Is the agency certified for participation in Medicare and Medicaid programs or private insurance? 

Does the agency accept payment from Long-term Care policies, Family Care or the Community Options Program? 

How long has the agency been serving the community? 

Is the agency accredited by the Joint Commission On Accreditation of Healthcare Organizations (JCAHO), or the Community Health Accreditation Program (CHAP), or other recognized accrediting body? Does it state this in its agency literature and contracts? 

Does the agency provide an initial assessment to determine if the patient would be appropriate for home care and what those services might be? 

Is there a fee for an initial assessment? 

Does the agency provide all services needed? Can it provide flexibility to meet the patient’s changing health care needs? 

How does the agency choose and train its employees? Are criminal background checks made? Are employees given drug screens? Does it protect its employees with written personnel policies, benefits packages and malpractice insurance? Are the employees boned and insured? 

Does the agency provide literature explaining its services, eligibility requirements, fees and funding? 

Does the agency have arrangements in place for emergencies? Are the agency’s caregivers available 24 hours per day, seven days per week or on what limited time basis? How quickly can they start? 

Are references from former clients and doctors available? 

What types of programs does the company have in place for assure quality care is provided? 

Will the agency go to bat for you if your insurance company, Medicare or Medicaid fails to cover a claim you and the agency thought should be covered?

These are some important things to consider in being an advocate in caregiving.